A Guide to Out-of-Network Insurance Billing for Plastic Surgeons

Billing insurance for patients with out-of-network (OON) benefits is a tricky process. But for many plastic surgeons, it’s worth navigating the complexities to get patients the care they need while still getting reimbursed. The good news? It’s entirely possible with the right strategies in place.

Below, we’ll break it down step-by-step, explore common challenges, and share real-world examples to help you master the OON billing process.

How Out-of-Network Billing Works

1. Verifying the Patient’s OON Benefits

This is where it all begins. Without verifying a patient’s insurance coverage, you’re flying blind. Here’s what to check for upfront:

• Does the plan cover out-of-network services? Some plans completely exclude OON coverage. If that’s the case, patients will need to go out-of-pocket for your services.
• Deductibles and coinsurance. Be prepared to explain these to patients. OON deductibles are often high (think $5,000 or more), and patients typically pay 30-50% after meeting it.
• Pre-authorization requirements. Many OON procedures still need prior authorization. Without approval, claims are likely to be denied.

Case Example: A patient schedules a breast reconstruction surgery. During verification, your billing staff discovers the plan requires pre-authorization—but the patient doesn’t meet the insurer’s “medical necessity” criteria. Without early discovery, billing this case would result in a denied claim and an unhappy patient.

2. Payment Collection Before or After the Procedure

OON reimbursement isn’t guaranteed. To mitigate risk, many plastic surgeons require patients to pay upfront.

Here’s how it works:

• Collect full or partial payment upfront and provide a Superbill (a detailed receipt with billing codes) for patients to submit to their insurer.
• Alternatively, some surgeons bill insurance directly and then “balance-bill” the patient for the difference between what insurance pays and your fee.

Pro Tip: Explain the upfront payment clearly during the consultation. Set realistic expectations about the likelihood and timeline of reimbursement. Patients appreciate transparency.

Case Example: A patient undergoes a rhinoplasty. Your clinic collects an upfront payment of $8,000. After submitting a claim, the insurer reimburses the patient $2,500 based on their “allowed amount.” You save time chasing reimbursement, and the patient knows exactly what to expect.

3. Submitting Accurate Claims

Accuracy is key when submitting OON claims. Even small mistakes can lead to delays or denials. Here’s your checklist for success:

• Use the CMS-1500 form (or electronic format).
• Include correct CPT codes (e.g., 19316 for breast reduction, 30420 for nasal reconstruction).
• Add appropriate ICD-10 diagnosis codes to justify medical necessity (e.g., M54.2 for neck pain due to macromastia).
• Attach detailed operative notes and supporting documentation.

Remember, insurers love asking for backup, so it’s better to provide comprehensive documentation upfront.

4. Handling Reimbursement

Here’s the hard truth: Insurers rarely pay you what your services are worth. They base payments on an “allowed amount” (often much lower than your fee).

• Insurers may reimburse just 50-80% of the allowed amount.
• Patients are responsible for the difference, also known as balance billing.

Case Example: You perform a septoplasty and charge $10,000. The insurer’s allowed amount is $2,000. The patient’s coinsurance is 20%, leaving them with $400 covered. The remaining $9,600? It’s your patient’s responsibility. Make sure they understand this before moving forward.

Key Challenges of Out-of-Network Billing (and How to Overcome Them)

1. Low Reimbursement Rates

Most insurers set their reimbursement rates based on “usual and customary” (UCR) fees. Unfortunately, these rates are notoriously low compared to the actual cost of procedures.

• Example: If your tummy tuck costs $12,000 and the insurer’s UCR is $3,000, even the most robust OON benefits won’t come close to covering your fee.

Solution: Proactively communicate costs and payment expectations to avoid surprises. Additionally, consider partnering with financing companies like CareCredit to make payments more manageable for patients.

2. Claim Denials and Delays

It’s no secret that insurers look for reasons to deny OON claims. Common reasons include:

• “Procedure not medically necessary.”
• Incorrect or incomplete coding.
• Missing pre-authorization.

Solution: Stay ahead of denials by meticulously documenting every detail. Develop an appeals process for denied claims, and invest in ongoing staff training to improve coding accuracy.

Case Example: A patient’s claim for breast reconstruction is denied for “lack of medical necessity.” Your staff quickly submits an appeal with additional patient history and operative notes, securing full reimbursement on the second attempt.

3. Patient Misunderstandings and Frustrations

OON benefits are complicated, and many patients don’t fully understand how they work. When they receive lower-than-expected reimbursement, they may become frustrated or even refuse to pay the balance.

Solution: Use easy-to-understand language during consultations. Break down the numbers and provide written estimates of expected out-of-pocket costs. This avoids costly misunderstandings.

4. Administrative Burden

OON billing requires more time and effort than in-network billing.

• Expect countless follow-up calls to insurers.
• Appeals may become the norm.
• Patients often need help filing claims or understanding reimbursement.

Solution: Delegate! Consider outsourcing to a medical billing service or hiring specialized staff trained in OON claims.

5. Legal Restrictions on Balance Billing

Several states, including California, New York, and Texas, have laws limiting balance billing for OON providers. The No Surprises Act (2022) also bans certain types of balance billing for emergency care.

Solution: Familiarize yourself with both state and federal regulations. When in doubt, consult a healthcare lawyer to ensure compliance

6. Single Case Agreements (SCA)

Single Case Agreements (SCAs) are specialized contracts negotiated between a healthcare provider and an insurance company to cover services for a specific patient at an agreed-upon rate. These agreements are typically used for services rendered out-of-network (OON) when a patient requires care that is not readily available within the insurance company’s in-network providers. SCAs allow providers to offer highly specialized or unique care without requiring patients to bear the full cost out-of-pocket, bridging a gap between insurance coverage and patient needs. They are particularly common in cases where the patient’s medical needs demand expertise or treatment options that cannot be met by the existing in-network resources.

SCAs are also beneficial for insurance companies, as they help ensure that their members receive necessary care, preventing potential complications or higher costs that could arise from delayed or insufficient treatment. However, negotiating these agreements can be complex, as they involve detailed discussions around rates, medical necessity, and the scope of care being provided.

Solution:

To effectively manage SCAs, it is essential to establish a streamlined and well-documented process for negotiating with payers. Start by clearly outlining the patient’s care requirements, including supporting documentation that highlights the medical necessity for the specialized treatment you are providing. Include specifics about why in-network providers cannot meet the patient’s needs, as this will be a critical point for justifying the agreement.

Additionally, document your rates and ensure they are competitive and reflective of the services you are offering. Transparency and thorough preparation are key to building trust with the payer and expediting the agreement process. Engaging an experienced billing or legal team to assist with negotiations can be invaluable, as they can help navigate complex payer requirements, address potential disputes, and ensure the terms of the agreement align with both the payer’s policies and your practice’s financial goals.

Lastly, monitoring ongoing SCAs and maintaining proper communication with all parties involved, including the patient, insurance payer, and your internal team, is crucial to ensuring a smooth process. By proactively managing these agreements, you can provide patients with quality care while maintaining financial sustainability for your practice.

Best Practices for Out-of-Network Billing Success

• Verify First: Always confirm a patient’s benefits before scheduling procedures.
• Clarify Costs: Provide clear, itemized estimates of what patients owe.
• Require Upfront Payment: Collect full or partial payment before the procedure.
• Use Detailed Documentation: Ensure claims are supported by strong operative notes and correct codes.
• Appeal Denials: Don’t take “no” for an answer. Many denied claims are overturned upon appeal.
• Outsource Billing: Professionals specialized in OON billing can save time and headaches.
• Offer Financing: Make costs more manageable by providing patient financing options.

Final Thoughts

Out-of-network billing is a double-edged sword. On one hand, it offers flexibility and often higher fees than in-network reimbursement. On the other, it’s a complex, time-consuming process that can frustrate patients and staff alike.

For many plastic surgeons, the best approach is to remain OON for cash-pay cosmetic procedures while going in-network for reconstructive surgeries. This balance ensures smoother operations and stronger patient satisfaction.

Would you like a sample OON benefits verification script or tips on navigating appeals? Drop us a message—we’re here to help!

Being an out-of-network plastic surgeon in the US has its perks—but let’s be honest, it comes with its fair share of challenges too. The primary hurdle? Patient affordability. Convincing patients to pay out-of-pocket for procedures when insurance isn’t covering the tab can feel like trying to sell snow in a snowstorm. But if you’re prepared, you can overcome this obstacle and turn “out-of-network” into a competitive advantage.

Here’s a deep-dive into the roadblocks and how you can tackle them head-on—with a scalpel-like precision.

1. High Out-of-Pocket Costs for Patients

For most patients, hearing “that’ll be $10,000 upfront” can feel like a gut punch.

• Common Scenario: A patient is eager for a rhinoplasty. They’ve saved up, but the minute they learn their insurance won’t chip in, they hesitate.
• Reality Check: Elective procedures like breast augmentations, facelifts, and liposuction aren’t covered by insurance at all. Even reconstructive surgeries often require pre-approval and lots of documentation.

Solution:

Make it as easy as possible for patients to understand costs. Offer bundled or transparent pricing (e.g., “Here’s exactly what $8,000 includes”) and emphasize the value of your expertise.

2. Competition from “Covered” Surgeons

Patients love a deal. When in-network surgeons can say, “This surgery is 80% covered by insurance,” it’s a tough act to follow. But here’s the thing—not every patient is looking for a bargain.

Flip the Script:

Highlight your strengths.

• Do you have advanced certifications?
• A proven track record of outstanding results?
• World-class before-and-after photos?

When you position yourself as the best choice (not the cheapest), you’ll start attracting patients who value quality over cost.

3. Administrative Hurdles & Paperwork Woes

Insurance companies don’t make life easy for out-of-network providers. You’ve probably faced these headaches before:

• Claim Denials. A medically necessary skin cancer reconstruction gets rejected due to “inadequate documentation.”
• Pre-approval Speed Bumps. Breast reduction surgery for a patient with chronic back pain gets delayed for weeks.

How to Navigate This:

• Dedicate a portion of your team to handle insurance negotiations. Your staff can guide patients through reimbursement requests or help with proper coding.
• Provide templates for appeals. For example, draft detailed letters patients can submit for medically necessary claims.

One plastic surgeon in New York shared how they resolved this problem by hiring a part-time “insurance advocate” dedicated solely to liaising between their practice, insurers, and patients. “It cut down patient frustration by at least 30%,” they said.

4. A Smaller Pool of Potential Patients

Being out-of-network limits your audience. Many patients can’t afford procedures without insurance, shrinking your funnel of opportunities. But here’s where you can thrive.

Find Your Niche:

One Dallas-based surgeon mastered the art of “mommy makeovers” and marketed exclusively to affluent moms through Instagram, where they showcased unbelievable transformations. Finding a niche turns potential scarcity into razor-sharp focus, attracting the exact clients you want.

5. Pressure to Offer Financing Options

“We offer financing plans!” You’ve probably seen competitors promote this as their go-to solution. Truth is, patients expect it. If you haven’t explored partnerships with companies like CareCredit or Alphaeon, now’s the time.

Pro Tip:

Bundle financing plans with other perks, such as post-op care packages or complimentary consultations. Showing you’ve thought about the patient experience beyond the wallet builds loyalty.

6. The “Too Expensive” Perception

Some patients jump to the conclusion that out-of-network equals unaffordable and unnecessary. Even worse, they assume you’re only for the ultra-rich.

How to Tackle It:

• Leverage social proof. Feature testimonials and success stories from patients who believed the extra cost was worth it.
• Share relatable case studies. For example, “Meet Jane, a golfer who couldn’t compete due to injury. We repaired her torn cartilage, which wasn’t covered by insurance, but now she’s back on the course pain-free.”

Why Being Out-of-Network CAN Be an Advantage

Sure, it’s not all sunshine and roses, but being out-of-network offers unique benefits for surgeons who know how to position themselves.

Here’s why it might actually work in your favor:

• Full Autonomy. Forget rigid insurance policies that dictate what procedures you can perform or how much you’ll get reimbursed.
• Patient-First Decisions. You control the patient experience without cutting corners just to fit insurer guidelines.
• Higher Profit Margins. When payments come directly from patients, you dodge the time and effort spent chasing down insurers for reimbursements.

How to Build Success as an Out-of-Network Surgeon

Successful out-of-network plastic surgeons rely on these strategies to thrive:

• Hybrid Models. Offer insurance-based options for reconstructive cases while keeping elective procedures strictly self-pay.
• Brilliant Marketing. Invest in showcasing your specialty. Results-driven photos and patient testimonials are worth their weight in gold.
• Showcase Value. From world-class customer service to state-of-the-art technology, remind patients what makes you stand out.

Real-Life Case Study

Dr. Michaels in LA decided to specialize in out-of-network cosmetic surgeries. He invested in world-class imaging technology to offer 3D previews of post-surgery transformations. Patients were willing to pay a premium because they felt confident in the results they’d get.

Another standout example is Dr. Rivera in Miami, who packages her services as “luxury experiences.” Her office provides spa-like amenities and VIP-level care, creating an atmosphere that justifies her prices.

The Bottom Line

Yes, being out of network comes with hurdles—but it also opens the door to immense opportunities. It’s about catering to the right audience, showcasing your value, and standing firm in the premium quality of your services.

Remember, it’s not about being “affordable” for everyone. It’s about being remarkable and unforgettable for the right people.

If you’re looking for guidance on fine-tuning your out-of-network strategy or transitioning entirely to a cash-based practice, we’re here to help. Let’s talk!

What’s Next? (hint: Bill with out-of-network benefits)

Stay tuned for our next blog, where we’ll explore the intricate process of how surgeons can bill insurances for patients with out-of-network benefits. We’ll break down the steps, discuss the challenges commonly faced, and provide insights to help you navigate this complex system with confidence. Whether you’re just starting or seeking to optimize your approach, this upcoming discussion will provide the clarity you need. Don’t miss it!

Payment Revolution in Healthcare Find Out the Magic Behind EFT ERA Enrollment 

If you’ve spent enough time managing healthcare payments, you know it’s not all sunshine and rainbows. Paper checks get lost, reimbursement delays are a common headache, and the manual labor involved can drive anyone up the wall. But what if there was a way to sprinkle a little magic over these issues? Enter EFT (Electronic Funds Transfer) and ERA (Electronic Remittance Advice) enrollment—a modern-day solution for seamless payments to healthcare providers. 

In this guide, we’ll unravel the mysteries of EFT/ERA enrollment, highlighting its importance, benefits, and how you can get onboard this payment revolution. Whether you’re a healthcare provider, medical billing professional, or healthcare administrator, this post is designed to offer valuable insights and practical tips to streamline your billing processes. 

Understanding the Dynamics EFT and ERA Explained 

Imagine a world where payments flow directly into your account without fuss, and detailed transactional information is just a click away. That’s the world of EFT and ERA. 

EFT is your trusted courier, ensuring that funds move seamlessly from payer to provider. No stamps required. Meanwhile, ERA is like the Rosetta Stone for your payments. It decodes complex payment information into a format you can easily digest. 

These two tools are reshaping the payment landscape in healthcare, offering a streamlined approach that’s faster, more efficient, and remarkably secure. 

The Perks Why EFT ERA Enrollment is a Game Changer 

Why should you consider enrolling in EFT/ERA? Hold onto your hats because the benefits are substantial: 

• Speed and Efficiency: Faster transactions mean quicker access to funds. No more waiting for checks! 

• Accuracy in Accounting: With ERAs, you get detailed payment information, reducing errors in financial documentation. 

• Cost Savings: Less paper, less hassle. Enjoy reduced administrative costs as you wave goodbye to traditional check handling. 

• Enhanced Security: EFTs and ERAs are fortified with security measures to protect sensitive financial information. 

Enrolling in EFT/ERA isn’t just a good idea; it’s a smart business move that can save both time and resources. 

Enrolling in EFT ERA A Step-by-Step Guide 

Ready to sign up? Here’s how you can make the smooth transition to EFT/ERA: 

Understanding the Enrollment Process 

The first step in your EFT/ERA enrollment is understanding the process. It typically involves: 

• Choosing a participating payer or clearinghouse 

• Completing an enrollment form 

• Verifying bank account information for EFT 

• Designating a contact person for communications 

Required Information and Documents 

Gathering the right documents in advance can save you from unnecessary back-and-forth. Typically, you’ll need: 

• Banking details for EFT (such as account and routing numbers) 

• Tax Identification Number (TIN) 

• National Provider Identifier (NPI) 

• Contact information for your finance or billing department 

Common Pitfalls to Avoid 

Even the best-laid plans can go awry. Avoid these common pitfalls: 

• Incorrect bank details leading to rejected EFTs 

• Delays due to incomplete forms 

• Communication breakdowns between departments 

It’s all about dotting your i’s and crossing your t’s—attention to detail goes a long way. 

Leveraging Third-Party Intermediaries Pros and Cons 

In the quest for a seamless transition to EFT/ERA, enlisting the help of third-party intermediaries can be a strategic choice. These companies specialize in bridging the gap between healthcare providers and payers, offering expertise to streamline the enrollment process and manage transactions effectively. However, as with any business decision, utilizing an intermediary comes with its own set of advantages and drawbacks. 

Pros: 

• Expert Guidance: Third-party intermediaries are well-versed in the intricacies of EFT/ERA enrollment and compliance, providing valuable insights and assistance to ensure successful implementation. 

• Time Savings: By handling the administrative legwork, these intermediaries can save healthcare providers significant time, allowing them to focus on their core responsibilities. 

• Enhanced Accuracy: With experience in processing payments and managing documentation, intermediaries can help reduce errors that might occur if managed in-house. 

• Scalability: As your practice grows, an intermediary can scale their services to accommodate increased transaction volumes efficiently. 

Cons: 

• Cost: Engaging a third-party service often involves fees, which could impact the overall cost savings of transitioning to EFT/ERA. 

• Reliance on External Parties: Relying on an intermediary means placing trust in an external entity to manage sensitive financial and billing information. 

• Potential Delays: While intermediaries work to streamline processes, any miscommunication or errors on their part can result in delays, much like pitfalls that occur in direct enrollment. 

• Vendor Lock-In: Once a provider partners with a specific intermediary, switching to another service or back to self-management could present challenges and cause disruptions.  

Opting to work with a third-party intermediary involves weighing these factors carefully and deciding based on the specific needs and capacities of your healthcare operation. 

Examples of Third-Party Intermediaries 

Choosing the right third-party intermediary is crucial for a successful EFT/ERA transition. Here are a few reputable companies that provide these services: 

• Zelis Healthcare: Known for its comprehensive suite of payment solutions, Zelis Healthcare offers integrated payment services that enhance speed, accuracy, and transparency. 

• Change Healthcare: This intermediary provides a robust platform with a focus on maximizing efficiency and improving payment processes, catering to both large health systems and smaller practices. 

• Availity: Availity specializes in provider engagement and billing efficiency, offering solutions that streamline administrative tasks and improve financial transactions. 

• Emdeon: With a strong emphasis on connectivity and healthcare payment integration, Emdeon helps manage complex billing processes with ease. 

Selecting an intermediary like these can provide the support and technology needed to navigate the complexities of EFT/ERA enrollment, giving healthcare providers peace of mind and operational efficiency. 

Tackling Enrollment Challenges 

Change can be daunting, but don’t worry. Here’s how to tackle some common hurdles: 

Addressing Resistance and Misconceptions 

Some individuals may be hesitant to switch from paper checks to digital payments. To address common misconceptions, highlight the security features, cost savings, and increased efficiency of EFT/ERA. 

Navigating Technical and Administrative Hurdles 

Technical hiccups and administrative red tape can be frustrating. Consider these strategies: 

• Collaborate closely with IT where applicable to ensure systems are compatible. 

• Foster open communication with payers and clearinghouses to resolve issues promptly. 

• Conduct training sessions for staff to familiarize them with the new processes. 

How EFT ERA Elevates the Payment Game 

With EFT/ERA, the healthcare payment landscape is transforming. Here’s how it’s making waves: 

Enhancing Efficiency and Accuracy 

EFT/ERA improves the speed and accuracy of payments. Billing becomes a breeze, and financial records are more precise than ever before. 

Boosting Security and Compliance 

Data breaches are a real concern, but EFT and ERA come with robust security protocols. Plus, they help you stay compliant with industry regulations. 

Slashing Administrative Costs 

With fewer papers to shuffle and fewer checks to handle, administrative costs shrink significantly. That’s more budget for the things that really matter. 

Real-Life Success Stories 

Here’s where the rubber meets the road. Many providers have already embraced EFT/ERA with great success: 

• Dr. Smith’s Clinic saw payment processing times drop from 30 days to just 7. 

• HealthCo Group reported a 20% reduction in administrative costs after switching to electronic payments. 

• The Care Center improved its billing accuracy by implementing ERA across all departments. 

These examples illustrate how EFT/ERA can transform your organization’s financial operations. 

What Lies Ahead – The Future of EFT ERA in Healthcare 

The world of healthcare payments is evolving, and staying ahead of trends is crucial. Here’s what’s on the horizon: 

AI and Machine Learning Integration 

Artificial Intelligence and machine learning are poised to further enhance EFT/ERA processes, offering predictive insights and automated reconciliation. 

Blockchain for Unmatched Security 

Blockchain technology may soon bring unparalleled security and transparency to healthcare payments, building trust and reliability. 

Real-Time Transactions 

Imagine payments processed in real-time. The future of EFT/ERA could very well include seamless transactions that happen instantly. 

Wrapping It Up: Take Action Today 

In a world where time is money, EFT/ERA enrollment offers healthcare providers a golden opportunity to streamline their payment processes. By understanding the enrollment process, tackling common challenges, and recognizing the benefits, you’re well on your way to a more efficient and profitable operation. 

Don’t wait. Take action today. Investigate your options for EFT/ERA enrollment and bring your payment processes into the modern age. For more information and support, consider reaching out to industry experts who can guide you through the transition smoothly. 

Ready to revolutionize your payment systems? Say goodbye to the old ways and hello to the future of healthcare finance with EFT/ERA enrollment. 

Let’s paint a scenario: You’re a healthcare provider out of network with an insurance company. Your patient has out-of-network benefits, but here’s the kicker—the insurance company sends the check directly to the patient. Frustrating, right? Don’t worry, we’ve got a guide to help you navigate this tricky situation and recover the money owed to you.

Step-by-Step Process for Recovering Money from Patients

1. Verify Insurance Coverage

Before you even start treatment, verify that the patient has out-of-network benefits. Understand the coverage details, including deductibles and co-insurance. This knowledge is crucial in setting clear expectations.

2. Transparent Communication

Have an open conversation with the patient about their financial responsibility. Explain what the insurance company covers and what they will owe directly. Trust me, clear communication here can save a lot of headaches later.

3. Documentation

Keep meticulous records of the treatment provided, the amount owed, and any communication with the patient or insurance company regarding payment. Documentation is your best friend.

4. Billing the Insurance Company

Submit a claim to the patient’s insurance company. Make it clear to the patient that you are an out-of-network provider and list the services provided. This ensures there are no surprises on either end.

5. Check for Errors

Regularly check the status of your claim. Ensure there are no errors and that it is moving through the payment process smoothly.

6. Check Mailing Address

If the insurance company sends the payment directly to the patient, make sure they have your correct billing address. This way, the patient knows where to forward the check.

7. Follow Up with Patient

Once you confirm via the insurance portal or clearinghouse that the check has been sent to the patient, follow up promptly. Request payment and offer multiple options for how they can make the payment—online, over the phone, or by mail. Flexibility can make a big difference.

8. Payment Plans

If the patient struggles to pay the full amount out-of-pocket, discuss setting up a payment plan. Find a solution that works for both parties. Compassion coupled with persistence can go a long way. Payment plans are not offered when the insurance company has sent the payment to the patient.

9. Legal Options

If all else fails and the patient does not make arrangements to pay, consult with a legal advisor. Explore your options but remember to keep this as the last resort.

10. Persistence

Maintain open lines of communication and be persistent in your efforts to recover the funds. Follow up regularly and keep the conversation going.

Real-World Scenarios to Illustrate the Process

Scenario 1:

A patient with out-of-network benefits undergoes a session with a therapist. The insurance company processes the claim and sends a check directly to the patient. The patient promptly informs the therapist. The therapist follows up with the patient, requesting to forward the check or bring it in person. The patient complies, and the therapist processes the check.

Scenario 2:

In another instance, a patient receives a check from their insurance company and forgets to inform the provider. After a month, the provider reaches out for payment, and the patient realizes they received the check but forgot to forward it. The patient immediately sends the check to the provider, who then processes it.

These scenarios highlight the importance of clear communication, documentation, and persistent follow-up to ensure timely recovery of owed funds.

Final Thoughts

Recovering money from patients when out of network can be challenging but not insurmountable. By following these steps and maintaining a proactive approach, healthcare providers, medical billing staff, and practice managers can navigate these tricky waters effectively. Your persistence, coupled with clear communication and thorough documentation, will ensure you recover the funds you’re due.

Got any other tips or experiences to share? We’d love to hear them in the comments below. And if you found this guide helpful, why not share it with your colleagues?

Stay persistent and stay informed!

Mental health is a critical aspect of an individual’s overall health and well-being. However, it can be challenging to get the right treatment, especially when it comes to billing claims. Denials of mental health billing claims have become more common, preventing patients from getting the care they need. When billing claims are denied, it creates more than just a financial burden; it can also cause patients to lose access to treatment and compromise their recovery. In this blog post, we will look into the top 10 reasons why mental health billing claims can get denied and how they can be prevented.

1. Inaccurate or Incomplete Patient Information

One of the reasons why mental health billing claims get denied is when patient information is inaccurate or incomplete. This includes missing or incorrect personal information, such as dates of birth, contact details, and insurance information. Providers must ensure that patient information is complete and accurate to avoid billing issues.

2. Lack of Medical Necessity

Insurance companies often deny claims when they do not believe that a service or treatment is medically necessary. Providers must document the medical necessity of any service provided and ensure that it aligns with the patient’s condition and diagnosis.

3. No Referral or Pre-Authorization

Insurance companies may require a referral or pre-authorization from a primary care provider before they cover certain mental health services or treatments. Providers should ensure they have obtained the necessary documentation before rendering any services or treatments to avoid denials.

4. Incorrect Billing Codes

Billing codes determine the charges for rendered services or treatments. If the wrong codes are used, it can lead to billing claim denials or potentially delay payment. Providers must ensure they are using the correct billing codes that align with the provided services and treatments.

5. Time Limit Exceeded

Providers have a limited amount of time to submit billing claims to insurance companies. If the provider misses the filing deadline, it can cause a rejection or delay of reimbursement. Providers must send out billing claims within the permitted timeframe to avoid denials.

6. Claims Exceeded Allowed Services

Insurance companies have pre-approved limits for certain mental health services or treatments. If the provider exceeds the allowed limit, it could lead to a denial of the billing claim. Providers should ensure that they follow the pre-approved limits to avoid claim denials.

7. Billing for Inappropriate Services or Treatments

Providers must make sure the services or treatments they bill for align with the patient’s condition and diagnosis. Trying to bill for inappropriate mental health services or treatments may trigger denials by insurance companies.

8. Using the Wrong Modifier Codes

Modifier codes provide additional information about the services or treatments that the provider delivers. Providers must ensure they use the right modifier codes to avoid billing claim denials.

9. Balance Billing

Providers may sometimes want to bill the patient for the balance of an amount that insurance does not cover. This is against insurance rules and can lead to claim denials. Providers must understand the policies of an insurance company and avoid balance billing.

10. Inadequate Documentation

Providers must ensure that they fully document the services and treatments rendered. Lack of adequate documentation may signal an insurance company of fraudulent activities, leading to claim denials.

Conclusion:

Billing claims denials can be frustrating, both for providers and patients. However, understanding the reasons why mental health billing claims get denied is essential to avoid them. Providers must ensure they provide accurate billing information and adhere to insurance policies and guidelines. By doing this, providers can avoid claim denials and help patients receive the care they need. Always remember these top 10 reasons and their corresponding preventive measures to avoid billing claims denials.

By Chandresh J. Shah

Growing a practice can take a lot of work and having goals can help. That is why it is important to have KPIs(Key Performance Indicators) that can be used to determine how well practice goals are being met.

Let me share to you KPIs that will help your practice on 4 main areas:

1. Front Desk 
2. Clinical
3. Billing and Revenue Cycle Management
4. Reputation Management

Let me begin with KPI’s for Billing and Revenue Cycle Management as they are the first point of contact and impression your practice makes with existing and new patients. These KPIs are:

14. Net Collections Rate

15. Total Operating Margin

16. Average Insurance Claim Processing time & cost

17. Average cost per patient

18. Claims Rejection rate

19. Average insurance claim processing time and cost

20. Average Treatment Charge

21. Percentage of Patients without Medical Insurance

22. Time Gap between Date of Service and Date Billed

23. Percentage of Claims Denied overall, and by Payer

24. Percentage of Claims Denied due to Front-end errors vs Coding oversights

25. Percentage of Patients with Public vs Private Insurance

26. Percentage of No-Response claims overall, by Payer

In the video below, I went through and explained what each KPI meant for the Billing and RCM. You can also download the guide through this link (Click Here):

By Chandresh J. Shah

Growing a practice can take a lot of work and having goals can help. That is why it is important to have KPIs (Key Performance Indicators) that can be used to determine how well practice goals are being met.

Let me share to you KPIs that will help your practice on 4 main areas:

1. Front Desk 
2. Clinical
3. Billing and Revenue Cycle Management
4. Reputation Management

Let me begin with KPI’s for Front Desk as they are the first point of contact and impression your practice makes with existing and new patients. These KPIs are:

1. Patient In-Office Wait Time
2. Schedule Density
3. Percentage of Electronic Health Records
4. Confirmation and No-Show Rates
5. Patient Phone Wait Times
6. Check-In Efficiency
7. Number of Patients Served Per Month
8. Number of New Patients Served Per Month
9. Number of Patient Referrals
10. Staff Time Spent Entering Data/Charting
11. Doctor-Care-to-Paperwork Ratio
12. Percentage of Patients Who Found Paperwork to be Clear and Easy to Understand
13. Patient Care Automation (i.e. paper work required)

Watch this “Top 40 KPI” video as I went through and explained what each KPI meant for the front desk. You can also download the guide through this link (Click Here):